Attachment A Required Submission Documents BIDDER INFORMATION

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1 Company Name: BIDDER INFORMATION Company Address: Authorized By (typed or printed name): Title: Authorized Signature: Date: Telephone Number: Fax Number : Address: Company s Web Page: Remit to Name: Remit to Address: REMITTANCE INFORMATION (where payments should be sent) City: State: Zip: County: Phone: Fax: Toll Free: Contact: Tax ID: SSN Federal Tax ID Business Type: Individual Business Misc. PURCHASE ORDER INFORMATION (where purchase orders should be sent) Purchase Order Name: Purchase Order Address: City: State: Zip: County: Phone: Fax: Toll Free: Contact: Payment Terms: Discount % No. Days Net Due Freight Terms: Ship Via: FOB MBE/DBE/WBE STATUS (check appropriate box(es)) African American Hispanic Native American Asian American Disabled Veteran Woman-Owned Not-Applicable

2 BIDDER QUALIFICATION FORM Company Name: Address: When Organized: Where Incorporated: How many years have you engaged in business under the present firm name? Credit available for this contract? Contracts now in hand? Has bidder ever refused to execute a contract at the original bid amount? Has bidder ever been declared in default on a contract? Comments: Company Name: Authorized By (typed name): Authorized Signature: Title: Date: References Following is a reference list of contracts that are similar to this project: NAME OF PROJECT/DATE LOCATION CONTACT PHONE # DAY OF, 201 My Commission Expires:

3 FINANCIAL & LEGAL STABILITY STATEMENT Please check appropriate item(s): Firm has the financial capability to undertake the work and assume the liability required if awarded this solicitation. Firm has the legal capability to undertake the work and assume the responsibilities required if awarded this solicitation. Pending litigations (if any) will not affect the firm s ability to perform on this contract, if awarded. Company Name: Authorized By (typed name): Authorized Signature: Title: Date: DAY OF, 201 My Commission Expires:

4 INSURABILITY STATEMENT Please check appropriate item(s): By submission of this form, this firm confirms the ability to acquire and maintain the required levels of insurance as outlined in the bid document. It is the understanding of this firm that proof of Insurance must be provided prior to contract execution and maintained throughout the entire term of the contract. Company Name: Authorized By (typed name): Authorized Signature: Title: Date: DAY OF, 201 My Commission Expires:

5 GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT Contract No. and Name: Name of Contracting Entity: By executing this affidavit, the undersigned person or entity verifies its compliance with O.C.G.A , stating affirmatively that the individual, firm, or corporation which is contracting with Bibb County has registered with, is authorized to participate in, and is participating in the federal work authorization program commonly known as E-Verify,* in accordance with the applicable provisions and deadlines established in O.C.G.A The undersigned person or entity further agrees that it will continue to use the federal work authorization program throughout the contract period, and it will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the undersigned with the information required by O.C.G.A (b). The undersigned person or entity further agrees to maintain records of such compliance and provide a copy of each such verification to Bibb County at the time the subcontractor(s) is retained to perform such service. Check if exempt EEV/E-Verify TM User Identification Number Date of Authorization By: Authorized Officer or Agent (Name of Person or Entity) Title of Authorized Officer or Agent Date Printed Name of Authorized Officer or Agent DAY OF, 201 My Commission Expires: * or any subsequent replacement operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the immigration Reform and Control Act of 1986 (IRCA), P.L

6 Macon-Bibb County Procurement Department 700 Poplar Street, Suite 308 Macon, Georgia Tel: (478) Fax: (478) CERTIFICATION REGARDING DEBARMENT, SUSPENSION INELIGIBILITY AND VOLUNTARY EXCLUSION The Bidder/offer certifies, by submission of this Proposal or acceptance of this contract, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded from participation in this transaction by any Federal department or agency. It further agrees by submitting this proposal that it will include this clause without modification in all lower tier, transactions, proposals, contracts, and subcontracts. Where the Bidder/offeror or any lower tier participant is unable to certify to this statement, it shall attach an explanation of this solicitation/proposal. Dated at this day of, Signature of Contractor: _ Title: For Macon Bibb County Personnel Only: Macon Bibb County Procurement Department will verify that the above bidder/offer certifies, by submission of this Proposal or acceptance of this contract, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded from participation in this transaction by any Federal department or agency. Signature of Procurement Officer Date Printed Name

7 NON COLLUSION AFFIDAVIT Date: Project: Project #: Project Description: Services Provided: State of: County of: Bibb County, Georgia General Contracting Georgia Bibb I, having first been duly sworn, deposes and states as follows: I am the party making the foregoing Proposal or Bid; that such Proposal or Bid is genuine and not collusive or sham; that said Proposer or Bidder has not colluded, conspired, connived, or agreed, directly or indirectly, with any Proposer or Bidder or person, to put in a sham Proposal or Bid, or that such other person refrain from proposing or bidding, and has not in any manner, directly or indirectly sought by agreement or collusion, or communication or conference, with any person, to fix the Proposal Fee or Bid Price of affiant or any other Proposer or Bidder, or to fix any overhead, profit or cost element of said Proposal Fee or Bid Price, or that of any other Proposer or Bidder, or to secure any advantage against Bibb County, Georgia or any person interested in the proposed Contract; and that all statements in said Proposal or Bid are true; and further, that such Proposer or Bidder has not directly or indirectly submitted this Proposal or Bid, or the contents thereof, or divulged information or data relative thereto to any association or to any member or agent thereof. Contractor: (Signature) (Seal)